Living with HIV, but dying of co-infections

Bobby Ramakant – CNS
HIV co-infections were in the spotlight at a few sessions on the second day of ICAAP. Neglecting infections with hepatitis C virus (HCV), hepatitis B virus (HBV), visceral leishmaniasis (VL), tuberculosis (TB), among other HIV co-infections and co-morbidities, threatens to reverse gains made by remarkable scale up of HIV-specific services.
Speaking at a UNITAID/UNAIDS/Indian Harm Reduction Network/WHO session, Dr Nick Walsh said that 10 million people who inject drugs (PWID) are exposed to HCV in 77 countries globally. The number of PWID with HCV is thought to be 3.5 times higher than those infected with HIV. An estimated 6.4 million PWID are thought to be infected with HBV, with 1.2 million developing chronic HBV infection.

In Asia and the Pacific, the majority of the countries are estimated to have more than 50% HCV prevalence among PWIDs. This includes countries such as Cambodia, China, India, Indonesia, Japan, Macau, Malaysia, Myanmar, Nepal, Pakistan, Philippines, Thailand and Viet Nam, among others.

“In Indonesia, HIV prevalence among PWIDs is estimated to be 36%, HCV prevalence is estimated to be 77.3% and HBV prevalence 57.6%,” said Edo Agustian from Indonesia, who is also a board member of Asian Network of People who Use Drugs (ANPUD). “Yet there are no national clinical guidelines for diagnosis, treatment and care for HCV-HIV co-infection or HBV-HIV co-infection in Indonesia.”

“In India, HCV rates among PWIDs are up to 90% in Manipur, ranging between 30 and 50% among PWIDs in cities such as Delhi and Chandigarh,” said Sutapa Deb of NDTV. In Australia, HCV treatment has been free since 2005 but only 8.6% of eligible PWIDs attending needle syringe exchange programmes have ever had HCV treatment. “In Myanmar, there is little data reported on HCV-HIV co-infection although community evidence suggests alarming rates,” said Willy de Maere of the Asian Harm Reduction Network in Myanmar.

“In Thailand, HIV rates among PWIDs are estimated to range between 30 and 35%, but HCV rates are 3-fold higher at 90%,” said Paisan Suwannawong of the Thai Treatment Action Group (TTAG). The Thai government had initially excluded HIV and HCV treatment when rolling out the ‘30 Baht’ health insurance scheme, but since 2003 HIV treatment was covered after pressure from treatment activists grew. “But HCV treatment is still not covered, even though the Thailand Government considered including HCV drugs in the national essential medicines list.”

“Evidence exists that providing antiretroviral therapy (ART) to HIV-HCV co-infected people is cost-effective and makes public health sense. Otherwise advancing HIV related illnesses leads to HCV progression,” said Dr Swarup Sarkar of UNITAID. “It is not possible to ‘get to zero HIV deaths’ without addressing HIV-HCV co-infection,” said Sarkar.

According to Tripti Tandon of the Lawyers’ Collective, HCV drugs are expensive because of patents on pegylated interferons. But despite a court decision revoking the patent, no generic drug manufacturer came forward to deliver HCV medicines to those in need. “Better quality drugs are in pipeline and expected to reach the people in-need by 2015,” she added.

Evidence shows reducing (or eliminating) HCV among PWIDs requires full harm reduction services, which can reduce HCV rates by 80% if opioid substitution therapy is combined with high coverage needle and syringe exchange programmes (NSP). Antiviral therapy can further reduce HCV prevalence by 50%. But there is “appalling access” to NSP across the region as a whole.

Dr Homa Mansoor of Medicins Sans Frontieres (MSF) said that in her clinical experience of treating HIV and HBV: “Viral suppression of both co-infections is important for better treatment outcomes. Ignoring one or the other will impact the co-infected person adversely.” She called for mandatory HBV screening for PWIDs in guidelines of the India National AIDS Control Organization (NACO). “HBV vaccination has only been recently introduced in the national immunization schedule for children but does not cover adults in India,” said Mansoor.

Bihar state in India is home for half of the world’s cases of visceral leishmaniasis (also known as Kala Azar). Petros Isaakidis of MSF said that VL is fatal in 90% cases if left untreated, although cutaneous infection usually heals by itself. 350 million people are at risk of VL in 88 countries. 1.5–2 million new VL cases occur every year.

“Leishmaniasis is an opportunistic AIDS-defining disease,” said Isaakidis. “MSF data shows that HIV and short-term mortality rates are very high in VL-infected patients, although number of patients in the study is small. Still this may be the largest cohort of HIV-VL co-infected people in the world,” said Isaakidis. Despite trends to show alarmingly high HIV rates among VL patients, HIV voluntary counselling and testing services are not routinely offered to VL patients. There are no national guidelines to deal with HIV and VL in India. MSF is offering HIV-related VCT to all VL patients in its project in Bihar.